Diagnostic challenges in primary care: Identifying and avoiding cognitive bias: These 4 cases demonstrate how cognitive bias can impede the diagnostic process.

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Date: Apr. 2022
From: Journal of Family Practice(Vol. 71, Issue 3)
Publisher: Jobson Medical Information LLC
Document Type: Article
Length: 4,916 words
Lexile Measure: 1560L

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Medical errors in all settings contributed to as many as 250,000 deaths per year in the United States between 2000 and 2008, according to a 2016 study. (1) Diagnostic error, in particular, remains a leading cause of morbidity and mortality in the United States and worldwide. In 2017, 12 million patients (roughly 5% of all US adults) who sought outpatient care experienced missed, delayed, or incorrect diagnosis at least once. (2)

In his classic work, How Doctors Think, Jerome Groopman, MD, explored the diagnostic process with a focus on the role of cognitive bias in clinical decision-making. Groopman examined how physicians can become sidetracked in their thinking and "blinded" to potential alternative diagnoses. (3) Medical error is not necessarily because of a deficiency in medical knowledge; rather, physicians become susceptible to medical error when defective and faulty reasoning distort their diagnostic ability. (4)

Cognitive bias in the diagnostic process has been extensively studied, and a full review is beyond the scope of this article. (5) However, here we will examine pathways leading to diagnostic errors in the primary care setting, specifically the role of cognitive bias in the work-up of polymyalgia rheumatica (PMR), ovarian cancer (OC), Lewy body dementia (LBD), and fibromyalgia (FM). As these 4 disease states are seen with low-to-moderate frequency in primary care, cognitive bias can complicate accurate diagnosis. But first, a word about how to understand clinical reasoning.

There are 2 types of reasoning (and 1 is more prone to error)

Physician clinical reasoning can be divided into 2 different cognitive approaches.

* Type 1 reasoning employs intuition and heuristics; this type is automatic, reflexive, and quick. (5) While the use of mental shortcuts in type 1 increases the speed with which decisions are made, it also makes this form of reasoning more prone to error.

* Type 2 reasoning requires conscious effort. It is goal directed and rigorous and therefore slower than type 1 reasoning. Extrapolated to the clinical context, clinicians transition from type 2 to type 1 reasoning as they gain experience and training throughout their careers and develop their own conscious and subconscious heuristics. Deviations from accurate decision-making occur in a systematic manner due to cognitive biases and result in medical error. (5) TABLE 1 (7) lists common types of cognitive bias.

* An important question to ask. Physicians tend to fall into a pattern of quick, type 1 reasoning. However, it's important to strive to maintain a broad differential diagnosis and avoid premature closure of the diagnostic process. It's critical that we consider alternative diagnoses (ie, consciously move from type 1 to type 2 thinking) and continue to ask ourselves, "What else?" while working through differential diagnoses. This can be a powerful debiasing technique.

The discussion of the following 4 disease states demonstrates how cognitive bias can lead to diagnostic error.


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Gale Document Number: GALE|A702237901